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Best Practices for Preventing and Managing Skin Tears Clay E. Collins BSN, RN, CWOCN, CFCN, CWS, DAPWCA, FACCWS Objectives Identify and Discuss normal skin anatomy Understand the physiologic changes in the skin associated with aging Discuss the Risk Factors associated with skin tears Discuss Assessment and Prevention strategies Understand treatment of skin tears based on Assessment findings Statistics In 2000, 420 million people, 7% of world population, were 65 and older. According to the 2000 US census, 1 in 8 people are over the age of 65 11 fold increase since 1900 July, 2003, 35.9 million in the US (12% of the population) were 65 and older. Of these 4.7 million were 85 and older By 2030, 1 in 5 Americans is expected to be 65 years or older Projections indicate that by 2030 the number of elderly in the world will rise more than 70% Skin Tears What is a Skin Tear? Skin Tear Definition – The inadvertent removal of the epidermis with or without the dermis by mechanical means. Trauma such as tape removal or blunt trauma such as bumping into furniture can lead to skin tears. Primarily on the extremities (80% on arms) Result of friction alone or shearing and friction Separates the epidermis from the dermis = Partial thickness wound Separates both the epidermis and the dermis from the underlying skin = Full thickness wound Skin Tears Skin tears are a major problem affecting the elderly and compromised individuals Estimated 1.5 million skin tears occur in institutionalized elderly each year Prevalence rates 14 -24% Painful May lead to infection Increase caregiver time and facility costs The Skin Dynamic, Regenerating organ Comprises 15% of the total body weight The body’s primary defense mechanism Skin Anatomy and Physiology 3 Functional and Anatomical Layers Epidermis - outermost layer comprised of five separate strata Dermis – Thicker layer that houses the hair follicles, sweat glands, and nerves Hypodermis/Subcutaneous Tissue – fatty layer beneath the skin that provides cushioning and protection Epidermis Outermost layer 5 layers of stratified epithelium Under age 60 Over age 60 No blood vessels nourishment and oxygen originates from capillaries in the dermis Up to 7 mm thick Merck Manual,2006 Skin Anatomy and Physiology Dermal-Epidermal Junction (Basement Membrane) Provides structural support Exchange of fluid and cells between skin layers Rete ridges/pegs - Epidermal downward, finger-like projections Dermal Papillae – upward projections Fit together like “tongue and groove” wood to anchor the epidermis to the dermis Skin Anatomy - Epidermis 5 Sublayers of Epidermis: 1. Stratum Corneum – outermost layer, also called the “horny layer”. Composed of dead keratinocytes. This layer is constantly being sloughed off and replenished from below 2. Stratum Lucidum – present in areas where skin is thick (i.e. soles of feet) and absent where skin is thin (i.e. eyelids, tympanic membrane) 3. Stratum Granulosum – only 1-5 cells thick 4. Stratum Spinosum – also called the “prickly layer” 5. Stratum Germinativum – single layer of cells that are dividing and reproducing and migrate outward. Skin Anatomy - Epidermis Stratum Corneum Stratum Lucidum Stratum Granulosum Stratum Spinosum Stratum Germinativum Basement Membrane Stratum Corneum Dead cells held together by lipids (creates waterproofing) “Brick and mortar” of skin A healthy stratum corneum provides the best line of defense against invasion Skin Anatomy - Epidermis Absence of Blood Vessels The cells that are alive get their nutrients via osmosis and diffusion from the capillary loops in the underlying dermis Immune System – Langerhans cells migrate from bone marrow and reside in the epidermis. Epidermal turnover rate – 28 days Major function is PROTECTION Dermis Mesh of collagen and elastin fibers provide bulk, strength, support, elasticity Sweat and sebaceous glands Hair follicles Rich in nerve and blood supply Hill MJ, 2003 Skin Anatomy - Dermis Dermis – the inner layer of the skin The thickest layer of the skin 0.3mm on the eyelids to 3.0mm on the back Dermal papillae interlock with the epidermal rete ridges and contain capillary loops that supply oxygen and nutrients to the overlying epidermis. Contains vascular plexus, lymphatics, and collagen Nerve endings penetrate into the epidermis Abnormal nerve function affects the skin because the lack of nerve stimulation slows keratinocyte mitosis and produces a shiny, atrophic skin (i.e. SCI) Skin Anatomy - Dermis Epidermal Appendages Subcutaneous Tissue Layer of fat Providing cushioning, insulation, and support for other tissue Nutritional storage Vascular supply Skin Anatomy Subcutaneous Tissue Hypodermis Contains adipose tissue, connective tissue, blood vessels, lymphatics, and nerve endings Adipose tissue provides protection from pressure and padding against shear forces The pt with inadequate subcutaneous tissue is at High Risk for deep tissue damage caused by shear force and pressure, especially if allowed to slide Age Associated Changes Elderly Skin Prolonged epidermal turnover time Collagen bundles shrink and cause wrinkling Rete ridges and Rete pegs flatten causing decreased cohesion of the layers which leads to increased risk for skin tears and epidermal stripping Reduced activity of sebaceous and sweat glands leads to dry skin Age Associated Changes Erratic loss of melanin production leads to gray hair and age spots Decreased sensory receptors = Increased risk of trauma/burns (pt less likely to recognize impending breakdown related to friction, pressure, etc…) Loss of Subcutaneous tissue = Increased risk of shear/pressure injury and reduced thermal insulation Age Associated Changes Decreased Immunocompetence of the skin = increased risk of skin cancer, fungal infections, other infections (Fx of Langerhans cells are decreased by up to 50%) Reduced blood flow to the skin = delayed wound healing Age Associated Changes Reduced cellular competence/increased senescence = cells are less able to carry out activities essential to repair = increased risk that wound will not heal Increased capillary fragility = capillaries will burst with light pressure causing purpura and bruising Problems Associated with Chronologically Aged Skin Decrease Strength Susceptibility to blister formation Increased bruising Skin Tears Nail fragility and ridges More severe blistering response Purpura Disruption of skin from friction and shear Skin laxity Increased wound dehiscence and infection Increased formation of ulcers due to trauma and pressure Senescence Slow cell turnover with slow and incomplete skin and wound healing Lack of response to growth factors Abnormal DNA with cellular atypia and cancerous neoplasms Abnormal cell growth with development of non-cancerous neoplasms Incomplete repair to cellular damage like UV light, oxidative stress Lack of normal apoptosis Osteomalacia and Osteoporosis due to Vitamin D deficiency Impaired Skin Barrier Increased risk for irritant contact dermatitis Dryness Pruritis Scaling, Fissuring, Cracking Increased injury from tape stripping Increased absorption of chemical/drugs through the skin Increase in transepidermal water loss Maceration of skin occurs more easily Tendency towards dermatitis due to dry skin irritation Skin Appendage and Vascular Problems Graying of hair and thinning Sebaceous hyperplasia and decrease in sebum Lack of thermoregulation from reduced sweating Reduced capillary perfusion with difficulty in thermoregulation and vascular reserve Decrease in Skin Protective Function More susceptible to sun damage due to melanocyte problems Irregular pigmentation Dermal capillary skin flow dysregulation and decreased dermal clearance Less aware of pending skin damage from decrease in nerve function and density Reduced skin lymphatic activity Increase in contact dermatitis and reaction to topical Ostomy/Wound Management 2006;52(9):24-35 irritants Altered Immunity Cancers Increase in Bacterial, Viral, and Fungal Skin and Deep Tissue infection T-Cell Lymphomas Risk for Autoimmune problems Assessment and Prevention Studies show that once a skin tear – related problem is identified , implementation of a prevention program aimed at identifying at-risk individuals and measures to protect the skin from injury will reduce the rate of skin tears Risk Factors Advanced Age (>85 yrs) Female Caucasian History of previous skin tears Compromised nutrition Dehydration Dry Skin Cognitive Impairment Altered Sensory Status Immobility (bed or chair bound) Vision Impaired Use of Assistive Devices ADL Dependence Total Care Resists Care Ecchymotic or bruised skin (Senile Purpura) 40% of skin tears associated with senile purpura Senile Purpura often causes a decrease in pain perception Long Term Corticosteroid use Risk Factors 50% of all skin tears are of unknown origin Skin Tears of known causes: 25% result from Wheelchair/Geri-chair injuries 25% from accidents involving bumping into objects 18-24% occur due to transfers and falls Skin Assessment All patients at risk for skin tears should have their skin assessed regularly. Good Lighting is needed. A good time is during bathing. Assess Skin for: Dryness Ecchymosis (bruising) Edema Erythema Pruritis (itching) Pain Assess extremities for: Color Warmth Edema Ulcerations Assess Environment Assess clothing for: Tightness Rubbing Prevention Strategies Staff education Identify patients at risk Recognize that aged skin is impaired Recognize fragile, thin, vulnerable skin, especially when associated with ecchymotic skin (senile purpura) Prevention Strategies Use care when providing full or partial assistance with ADL’s since these tasks increase contact with the skin thus increasing potential for the skin to tear Use of appropriate equipment (i.e. lifts, walkers, transfer and turning aides, etc..) to assist with toileting and transferring Prevention Strategies Keep pt well hydrated Nutritional Support Implement measures to protect skin from injury such as: Skin sleeves Padded side rails Gentle skin cleansers Skin moisturizers Prevention Strategies Skin Cleansing Measures to Keep Skin Healthy Utilize pH balance cleansers and avoid alkaline soaps Alkaline products remove skin lipids which increases water loss and compromises the barrier function of the skin Use non-alkaline soaps for patients with dry skin Cleanse Goals of Skin Care Program Bathe qd or less Soap & water? Use pH balanced, lipid-based cleansing lotions Use tepid, not hot water Bathing systems & shampoo cap Incontinence cleansing Immediately and after each episode 32 Moisturize Skin normally transpires moisture (1 liter per day) often leading to excessively dry skin Products should prevent e-TEWL (excessive transepidermal water loss) Dimethicone/silicones prevents e-TEWL Prevention Strategies Skin Moisturizers The most important factor for healthy skin is adequate moisture Emollients moisten and lubricate the skin Lotions are suspensions of oily chemicals in alcohol and water and contain two major ingredients: Humectants such as glycerin that draw moisture into the skin’s surface Barrier ingredients that trap moisture in the skin Prevention Strategies Skin Moisturizers Emollients (Natural Oils – sunflower, safflower, olive and canola oils) Emollients penetrate into the stratum corneum to increase the lipid component and add softness plus they leave an oily film on the epidermis to retard water loss and help to rehydrate the stratum corneum Moisture Barriers (Dimethicone and other silicones) Help to retard water loss and to retain lipids and water within skin cells Prevention Strategies Skin Moisturizers Humectants ( Glycerin, urea, propylene glycol) These act as “water attractants” – they pull water from environment They increase the water component of the stratum corneum Protect and Nourish Ideally, products should be breathable and not occlude the pores Improve skin integrity with nutrients, amino acids, vitamins, antioxidants Protect and Nourish Primary barriers Sealants Ointments Creams Protect Second generation barriers Remains in contact with skin, is not absorbed Allows for healing even with repeated chemical assault May contain zinc oxide, starch powders, dimethicone, and other silicones Decreasing the Incidence of Skin Tears… An Evaluation of Costs and Effects of a Nutrient-Based Skin Care Program as a Component of Prevention of Skin Tears in an Extended Convalescent Center. Marge Groom, BSN, MSHCA, RN, CWOCN, Ronald E. Shannon, MPH, Debashish Chakravarthy, PhD, Cynthia Fleck, BSN, RN, CWS Decreasing the Incidence of Skin Tears… Switched to Nutrient-Based skin care regimen Education included staff, resident and family One LTC facility 100 residents Decrease from 180 to 2 skin tears Skin Tear Study Treatment Nutrient-Based Skin Care PetrolatumBased Skin Care 6-Month Labor and Supply Cost of Wound Treatment 2 Average Labor and Supply Cost of Skin Tears (2-week treatment) $21.96 180 $21.96 $3,866.40 Difference $3,822.48 Number of Skin Tears $43.92 Skin Tear Study Conclusion The analysis proved fiscally responsible Decreased the number of skin tears Provided comfort to the residents Empowered staff Prevention Strategies Skin tears resulting from adhesives: Appropriate application and removal of tape Stabilize skin while peeling tape away slowly Skin prep/liquid barriers Solvents (adhesive remover) – may dry skin Use of solid wafer skin barriers, thin hydrocolloids, low adhesion foam dressings, or skin sealants under dressings Use of porous tapes Avoidance of unnecessary tape use Prevention Strategies Protection of ecchymotic skin: Keep arms and legs covered with rolled gauze Long sleeves and pants Transparent dressings* Thin hydrocolloids* Low-adhesion foam dressings *Anytime adhesive dressings are used on intact skin to prevent skin tears, the dressing should not be changed routinely but should be left undisturbed and allowed to fall off. Skin Tear Classification Payne-Martin Classification System Most commonly used instrument to classify or describe skin tears Based on level or amount of tissue loss Payne-Martin Classification System Category I: Skin Tear can fully approximate wound Linear Skin Tear - Full thickness wound that occurs in wrinkle or furrow of skin. Both epidermis and dermis are pulled apart as if an incision has been made, exposing tissue below. Flap-type skin tear – Partial thickness wound in which the epidermal flap can be completely approximated or approximated so that no more than 1mm of dermis is exposed Category II: Skin Tear with partial thickness loss Scant Tissue Loss – Partial Thickness wound in which 25% or less of the epidermal flap is lost and as least 75% of underlying dermis is covered by flap. Moderate to Large tissue loss – More that 25% of the epidermal flap is lost and more than 25% of the dermis is exposed Category III: Skin Tear with complete tissue loss A Partial Thickness wound in which an epidermal flap is absent Payne-Martin Classification System Category I--skin tears without tissue loss. In a Linear type Category I skin tear, the epidermis and dermis have been pulled apart, as if an incision had been made. In a Flap type Category I skin tear, the epidermal flap completely covers the dermis to within 1 mm of the wound margin. Payne-Martin Classification System Category I This is a linear type skin tear. Note areas of senile purpura Payne-Martin Classification System Category I This flap type skin tear has an epidermal flap covering the dermis to within 1 mm of the wound margin. Payne-Martin Classification System Category II - skin tears with partial tissue loss. With a scant tissue loss type Category II skin tear, 25% or less of the epidermal flap is lost. When more than 25% of the epidermal flap is lost, the Category II skin tear is referred to as a moderate to large tissue loss type skin tear. Payne-Martin Classification System Category II Less than 25% of the epidermal flap has been lost in this scant tissue loss type skin tear Payne-Martin Classification System Category II More than 25% of the epidermal flap has been lost in this moderate to large tissue loss type skin tear. Payne-Martin Classification System Category III--skin tears with complete tissue loss. The epidermal flap is absent in this type of skin tear. Payne-Martin Classification System Category III The epidermal flap is absent in this skin tear Treatment of Skin Tears Skin Tear treatment should be based on: Fragility of the person’s skin Need to protect surrounding skin Utilization of moist healing principles Extent of tissue injury Treatment of Skin Tears Traditional dressings: Transparent Films Do not handle fluid well Pooling and leaking of fluid onto surrounding skin Adhesive - can cause epidermal stripping or tearing of the skin upon removal “Non-adherent” pads with topical antibiotics Adhere to skin and wound and can cause damage with removal Do not provide an optimal moist environment for healing Require more frequent changes More costly and labor intensive Treatment of Skin Tears Experts generally discourage use of transparent and hydrocolloid dressings because their removal can cause more skin damage and pain Alternatives include: Hydrogel sheet dressings (DermaGel, Elasto Gel) Petroleum based dressings (Xeroform, Vaseline Gauze) Non-adherent gauze (Adaptic, Oil emulsion dressings, Mepitel, etc..) Non-adherent Foam dressing Zinc Oxide Sample Skin Tear Protocol Treatment of Skin Tears Gently cleanse with Normal Saline or Wound cleanser *Remove blood from underside of flap before re-positioning over the wound bed Using a Cotton tipped applicator, Gently roll skin flap into place, unrolling edges so as to cover as much of exposed wound bed as possible. *Important to replace all viable skin as this is the best dressing available and will protect the wound while new skin grows Secure edges with Steri-strips – (Caution: traction on periwound skin can cause further damage) Cover with Hydrogel sheet Dressing (DermaGel) Secure with roll gauze and Self Adherent bandage (Co-Flex) or tubular wraps (Medigrip) or net stockings Avoid taping directly on skin Place an arrow on dressing to indicate the direction of the skin tear Change dressing q 3-5 days depending on amount of drainage Treatment of Skin Tears Minimize dressing changes to decrease risk of trauma to wound Most dressings can be left in place for up to 5 days Treatment of Skin Tears Important to choose dressings that allow you to: Avoid adhesives Decrease dressing changes Maintain an optimally moist wound healing environment Treatment of Skin Tears No tissue loss and minimal exudate: (q 3-5 days) Cyanoacrylate Liquid Skin Protectant Hydrogel Sheet Dressing + Wrap/Elastic Tubular Gauze Petroleum based gauze + Wrap Gauze Non-adherent gauze (Adaptic, Oil emulsion dressings, Mepitel, etc..) + Wrap Gauze Zinc Oxide + wrap gauze Cyanoacrylates Hydrogel Sheet Dressings Treatment of Skin Tears Tissue Loss and moderate amount of exudate (q 1-5 days) Hydrogel Sheet Dressing + Wrap/Elastic tubular gauze Non-Adhesive Foam Dressings + Wrap/Elastic tubular gauze Polyacrylate Dressing + Wrap/Elastic tubular gauze (q 24 hours) Documentation Skin tears are typically noted by thickness (Partial Thickness or Full Thickness) or by Category Document: CATEGORY or TYPE of the skin tear wound care treatment interventions measures implemented to prevent further skin tears Conclusion Skin Tears are common in the elderly with more than 1.5 million each year in adults in health care facilities Age related skin changes increase the risk of skin tears in the elderly Identifying those at risk for skin tears and implementing prevention strategies can reduce the incidence of skin tears Studies indicate that the majority of skin tears will heal in 7 to 21 days depending on the severity of the skin tear Skin tear treatment should be based on the fragility of the person’s skin, the need to protect the surrounding skin and utilization of non-adherent dressings References Ayello EA. Preventing pressure ulcers and skin tears. In: Mezey M, Fulmer T, Abraham I, Zwicker DA, editor(s). Geriatric nursing protocols for best practice. 2nd ed. New York (NY): Springer Publishing Company, Inc.; 2003. p.165-84. National Guideline Clearinghouse. www.guideline.gov. Bank D, Nix D. Preventing Skin Tears in a Nursing and Rehabilitation Center: An Interdisciplinary Effort. OWM. 2006; 52(9):38-46. Baranoski S. Skin Tears: Staying on Guard against the enemy of frail skin. Nursing2000. 2000; September. Bryant R, Clark R A. Skin Pathology and Types of Damage. Acute and Chronic Wounds: Current Management Concepts. 3rd edition. Mosby. 2007. Fleck CA. Preventing and Treating Skin Tears. Advances in Skin & Wound Care. 2007;20(6):315-321. Flemister B. A Compendium of case studies on the management of a variety of chronic wounds utilizing a breakthrough in interactive wet therapy. Presented at the 15th Annual Clinical Symposium on Advances in Skin & Wound Care. Nashville, TN. 2000. Fore J. A Review of Skin and the Effects of Aging on Skin Structure and Function. OWM. 2006; 52(9):24-35. Jones JL. Understanding Skin Tears: the “Whys” and “Hows”. ECPN. 2007; Jan/Feb. Milne CT and Corbett LQ. A New Option in the Treatment of Skin Tears for the Institutionalized Resident: Formulated2-Octylcyanoacrylate Topical Bandage. Geriatric Nursing. 2005;26(5):321-325. Payne RL and Martin ML. Defining and classification skin tears: need for a common language. OWM 1993;39(5)16-26. Ratliff CR, Fletcher KR. Skin Tears: A Review of the Evidence to Support Prevention and Treatment. Ostomy Wound Management. 2007; 53(3):32-42. Roberts M. Preventing and Managing Skin Tears. JWOCN 2007;34(3):256-259. Thank You Questions? Clay E. Collins BSN, RN, CWOCN, CFCN, CWS, DAPWCA, FACCWS